Take the care to the patient: Co-designed principles for establishment of a virtual hospital

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Fisher, Belinda Moshi, Kelly McGrath, Andrew Barron, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4683810/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Mar, 2026 Read the published version in Scientific Reports → Version 1 posted 12 You are reading this latest preprint version Abstract We aimed to inform design and implementation of a new Australian private virtual hospital by establishing co-designed principles and themes to inform a ten-year vision. This qualitative pre-implementation co-design study used an implementation science approach informed by the PERCS framework. Three workshops were held, one face-to-face in Brisbane, Australia, and two online. In each workshop, results of a prior barriers/enablers/considerations study were presented and critiqued by participants, followed by activities in focus groups. Thirty-six stakeholders from metropolitan, regional and rural areas participated including consumers, carers, health and aged care leadership, nurses, allied health providers, general practitioners, researchers, and public health stakeholders. There was strong enthusiasm, with some reservations such as clinical safety concerns. Four strong themes emerged: 1) Take the care to the patient; 2) Virtual is the mechanism, the care is real; 3) Be ambitious, but build a strong foundation; 4) Build the right workforce. These themes were repeated across all workshops, indicating good reliability of results. The strongest overall messages were the need for authentically patient-centred care and safety. Participants agreed that “safety first” underpinned all principles. Using an implementation science-informed, pre-implementation co-design approach led to stakeholder enthusiasm and findings which will inform implementation of the virtual hospital. Health sciences/Health care/Health services Health sciences/Health care/Occupational health Figures Figure 1 Introduction In recent years there has been a rapid global expansion of virtual hospitals, virtual wards, and hospital in the home services, henceforth referred to collectively as “virtual hospitals.” Research evidence is critical to inform healthcare decision makers considering implementing a virtual hospital. However, although there is strong evidence for the safety and clinical effectiveness of virtual hospitals, 1–3 implementation research has lagged. 4,5 There is substantial variance between models of care described as virtual hospitals, 3 and little guidance on selection or design of a suitable model of care for various healthcare settings and needs. There is acknowledgement in the literature that implementation of many virtual hospitals has been rushed in the context of the COVID-19 pandemic. 6–8 One study described setting up a COVID-19 virtual ward as being like building a plane while flying it. 6 Consequently, the majority of existing implementation literature has been retrospective and reliant on participant reflections. 4 Of the few published pre-implementation studies, 9–11 only one reported a collaborative design process, 10 and none used authentic consumer-inclusive co-design methods. Co-design in healthcare brings together health consumers and other stakeholders such as clinicians, healthcare executives/decision makers, informal/family carers, community and government representatives to develop solutions to complex healthcare problems. 12–14 Typically the goal or problem is pre-defined, and stakeholders come together through a range of methods to provide input and ideally agree on solutions. These collaborative processes aim to design healthcare services that are fit-for-purpose for consumers and healthcare providers alike, enable knowledge mobilisation, and reduce research waste. 13,15,16 . Although Dinesen et al. 10 described using a pre-implementation ‘design panel’ of clinicians to guide workflows and clinical processes of a hospital-in-the-home, no consumer or carer involvement was reported. One previous grey literature virtual hospital co-design study was identified. 17 My Home Hospital in South Australia used a co-design process to develop a clinical pathway and patient journal prior to commencement of a public hospital-in-the-home service. No research that addressed the development of a long-term vision or overarching principles of a virtual hospital was identified. Having a long-term strategic vision and clear set of principles are integral components of virtual hospital design according to healthcare stakeholders. 17 (reference to Manuscript 1, submitted to Scientific Reports) This research aimed to inform the design of a new private Australian virtual hospital by: ( 1 ) understanding the virtual healthcare needs, preferences and perspectives of a broad range of stakeholders; and ( 2 ) agreeing upon themes to inform a shared vision and set of principles. Methods A qualitative pre-implementation co-design study in July-Sep 2023 which involved three workshops with key stakeholders, one face-to-face in Brisbane, Queensland and two online. This study was the second phase of a research program to inform the design and implementation of a private Australian virtual hospital. The first phase was a context assessment to determine contextual barriers and enablers to implementation. The context assessment results and additional information about the setting and theoretical approach used are reported elsewhere (reference to Manuscript 1, submitted to Scientific Reports). This manuscript reports results of the co-design workshops only. This research was informed by the Planning and Evaluating Remote Consultation Services (PERCS) implementation science framework. 18 PERCS was developed during the COVID-19 pandemic to inform the rapid roll-out of virtual consultations in the United Kingdom’s National Health Service. It provides an evidence- and theory-based conceptual framework and guidance on stakeholders that need to be considered in the planning for remote consultation services. Objectives To identify and agree upon components (themes) of a ten-year vision to inform ongoing design and development of the virtual hospital. To identify and agree upon recommended principles for the virtual hospital. Co-design process Three workshops were conducted. Each workshop was audio recorded. The face-to-face workshop was two hours, and the two online workshops were 90 minutes. Participants were informed that they were welcome to provide additional written feedback by email in the two weeks following the workshop. Each workshop consisted of a series of activities in the full group, and in small focus groups. Each focus groups was facilitated by a member of the research team to ensure that conversations remained focused on the research question and all participants had the opportunity to share their perspectives. Participants attended one workshop only and were not informed of the results of previous workshops. To minimise the potential impact of any imbalance of power between participants, e.g., a health consumer and a doctor in the same focus group, the activities involved both group discussions and opportunities to provide individual and anonymous feedback. Workshop activities: Critique and confirmation of the context assessment results . Each workshop commenced with a presentation of context assessment results, followed by a whole-of-workshop group activity to critique and/or confirm the results. A summary of the responses was written on the whiteboard by the workshop facilitator and participants had the opportunity to provide clarification or correction of the summarised findings. Critique of the vision and principles . A draft ten-year vision and set of principles derived from the context assessment results were presented and participants split into focus groups of between three to six people, each with a facilitator from the research team, to critique the drafts. Each focus group then provided feedback to the whole-of-workshop group, which was summarised on a white board by the workshop facilitator. The summary was checked and clarified with participants during the discussion. Development of next steps . Participants were asked to consider the tasks/steps required to reach the vision within ten years. Steps were developed individually and shared anonymously by either 1) using post-it notes placed along a timeline in the face-to-face workshop; or 2) on a shared OneDrive file with a ten-year timeline which all participants were able to edit anonymously during the online workshops. Participants Purposeful selection was used to identify participants. All participants of a phase one interview (n = 37) were invited to a workshop unless they had previously expressed that they were not interested in attending a workshop (n = 1). Additional stakeholders who had not been interviewed were identified by the research team using a snowball sampling strategy. The focus of participant selection was on representation of key stakeholder groups and roles, as outlined in results Table One. Therefore, sample size and selection was focused on representation rather than data saturation. Qualitative analysis Following each workshop the research team conducted a one-hour debrief session to discuss initial impressions, emerging themes, reflections on engagement and participation, and any necessary process-related adaptations for future workshops. These debrief sessions were recorded and transcribed and formed part of the analysis process. Because of the value of inductive coding, we chose to use a pragmatic thematic coding methodology where we coded point (topic) by point, not line by line. 19 . In this way, we were able to develop descriptive codes and themes that accurately represented the data, within the health service’s required timeframe. OF and BM coded all workshop transcripts, and regular discussions were held with CG to agree on and confirm the descriptive codes and themes. These were then compared with the debrief session transcripts to ensure alignment. Data Storage All electronic data were stored on secure password-protected servers managed by the research institute, and paper-based data were stored in a locked file storage in a secure swipe-card access facility. Data management and retention complies with the National Health and Medical Research Council’s Management of Data and Information in Research guide. Ethical Considerations and Approval Participation was by informed consent. To avoid any potential perception of coercion to participate, consent was obtained by a member of the research team who did not have any supervisory relationship with the participant. To address any potential influence that imbalance of power between group members might have on participant responses during the workshop the activities included opportunities to provide feedback in small, facilitated focus groups, in the whole group, and individually. There was also an option to provide written feedback directly to the research team following the workshop. Ethical approval was received on 9 January 2023 from the UnitingCare Queensland Human Research Ethics Committee, Reference: Fisher_20221207. This research was conducted in accordance with the relevant guidelines and regulations. Results Participants Eight focus groups were facilitated across the three workshops. The majority of participants (n=26, 72.22%) attended an online workshop, with three (8.33%) attending from outside of a metropolitan area (Table 1). One participant provided additional written background information in the week following the workshop by email. [INSERT TABLE 1 HERE] Themes and Subthemes No participant identifiers have been included for workshop quotes because it was not possible to accurately identify each participant from the audio recordings due to the large size of some groups. Participants confirmed the considerations, enablers and barriers identified in the context assessment. There was strong alignment in responses across the three workshops, with the exception of a greater focus on rural and remote issues in the online workshops. Participants were enthusiastic about the potential of the virtual hospital and stated that they appreciated the opportunity to provide input from their perspectives. Across the three workshops, the following overarching themes and sub-themes emerged: Theme One: Take the care to the patient Workshop participants reported that the major advantage of a virtual hospital, as opposed to care provided in a physical hospital, is that patients can receive hospital care in their own homes, avoiding unnecessary travel and time away from their communities. Sub-themes: a. Create and address demand for timely healthcare ‘in place’: Customers and patients are beginning to expect convenient and timely virtual health services, which are accessible in their own homes or communities – i.e., ‘in place’. However, it was acknowledged by participants that work is needed to effectively build familiarity with and greater demand for these ‘in place’ services in the general population. Younger people were seen as central to developing this demand within the community. “One of the questions that I would love answered is, ‘if you could have your care episode… at home… do you think you would take advantage of that?’ Because I found that most people haven't even thought about it… It doesn't occur to the clinicians, and it doesn't occur to the to the patients or carers either. And it doesn't need to be in their own home, it could be in their daughter's home or their son's home or their parent's home. And it's just sort of and thinking about and, and if that had to happen, what would need to be in place for that?” b. Removing geographical boundaries: There was strong support for provision of virtual hospital services to rural and remote areas. c. Inclusive and appropriate : Provide patients with services that are culturally appropriate, accessible and inclusive for people from diverse backgrounds. d. Support the transition between services : Real-time communication between services is critical to smooth patient transitions. Patients frequently transition between public and private healthcare providers, ambulance, general practice, and aged care providers. Currently, there is a lack of streamlined communication between services to enable smooth transitions, which can be challenging for both patients and carers, and providers. Improving transitions through care navigation or more effective communication strategies is important. “And I would like to think that we would be partnering with public hospitals or statewide systems working that, that we know patients do flit from public to private and that they would need a system in place where the virtual records would be accessible by all.” Theme Two: Virtual is the mechanism, the care is real Participants felt strongly that virtual healthcare must be of equivalent safety and quality to face-to-face healthcare. The ability to develop trusting relationships between providers and patients was seen as critical, and there was variance in responses about whether this is possible via telehealth. Subthemes: a. Less than a physical hospital: There was a perception from some participants that the term “virtual” indicated that the care was not “real,” raising the question of whether the language of “virtual hospital” may need to be amended. There was a lack of agreement on this point, which indicates the need for a clear definition of virtual healthcare. Concerns about the need for physical examination were raised by multiple participants. The importance of supportive physical touch as part of a healthcare consultation was raised, and some participants believed that this was a major limitation of telehealth. “Personally, I have a very different feeling with the word virtual. The feeling I get is ‘not real’.” b. More than a physical hospital: Rapidly advancing technology is opening opportunities for monitoring that is likely to be more accurate and potentially faster at detecting changes in patients’ clinical presentation than previously possible. “Hospitals harm people” was a consistent message in both the context assessment and co-design studies. Hospital acquired infection was a major concern raised about traditional hospitals, as well as difficulties for some patients in adapting to a ward environment, e.g., patients with dementia, which can result in confusion, falls, and other adverse outcomes. “We know for many reasons it's safer from the infection perspective and a number of other things, they are with family, they [family] can provide care, but they [patients] really need… the input of their doctor.” Participants felt that younger people adapt more easily to new technologies and are less likely to see virtual healthcare as inferior to face-to-face. Younger people were described as easily forming relationships with people online, without the need for face-to-face contact. Theme Three: Be ambitious, but build a strong foundation. There were many comments relating to building a strong foundation for the hospital, particularly relating to safety, procedures, clinical governance, and appropriate technology. These foundational elements were seen as required precursors to any new services. Subthemes: a. Safety first : This was one of the strongest messages from the co-design workshops. Safe care was seen as separate to high-quality care, and both were considered necessary. b. Technology that’s fit for purpose : Participants raised the need for technology that is Easily adaptable to incorporate new services and technologies as they are developed. Reliable. Affordable for both the health service and the patient. Able to integrate with other existing systems. Easy to use, both for providers and consumers/carers. Trained with First Nations and diverse voices. “Everybody in our [focus] group has had the experience of having programs that don't talk to each other, unstable platform that we're managing programs on that we-, you know, program falling over, IT not being in a stable environment, programs going down, no accessibility.” c. More than just acute care : Participants were enthusiastic about the possibility of providing comprehensive care to patients, including acute, sub-acute, proactive and rehabilitation services via the virtual hospital. d. Must be cost-effective : Both for the healthcare provider and for patients. Participants described advantages to patients such as reduced travel time and expenses, as well as additional costs to informal carers such as time off work or away from usual tasks to support a virtual hospital patient. Theme Four: Build the right workforce The “right” workforce was described as one that is comfortable with technology, able to take on the responsibility of autonomous patient care, and ideally co-located to encourage interdisciplinary collaboration, effective communication, and planning. Subthemes: a. Workforce opportunities : For health professionals who have barriers to being able to provide face-to-face care e.g., due to injury, a virtual hospital may be an opportunity to enter, extend or patch their healthcare career. The flexibility that virtual healthcare offers providers was seen as an important advantage to attract a high-quality workforce. b. Informal carers are a critical workforce : Participants felt that without the important contribution of informal carers supporting patients at home during the admission the virtual hospital would not be viable. Participants therefore felt that the increased burden of care and responsibility on carers was important to consider, including the potential emotional toll of taking on a role that may require monitoring and escalation if a patient’s health declines. “You're taking the work that would normally done by the health care system and requiring the carers to do it. And we need to be immensely aware of the personal cost… Often that's not accounted for in business statements and financial assessments… it takes you out of workforce and other activities in your life, whether they're volunteering, caring for children or other activities.” Principles Both “patient centred” and “safety first” were raised by the majority of focus groups as the key principles for the Virtual Hospital and this was confirmed in whole of workshop group discussions. The opportunity to provide truly patient-centred care in their own home environment or community was considered a distinct advantage of virtual healthcare. Through collaborative discussions, the groups identified that “safety first” needed to underpin all principles, rather than being a standalone principle, leaving “patient centred” as the highest priority principle (Figure 1). [INSERT FIGURE 1 HERE] Discussion There was strong alignment of themes across the three workshops: 1) take the care to the patient; 2) virtual is the mechanism, the care is real; 3) be ambitious but build a strong foundation; and 4) build the right workforce. Using a co-design approach created enthusiasm and buy-in from the invited stakeholders, who were able to express and discuss their ideas, concerns, and considerations. The robust discussions between varied stakeholders in the workshops meant that a diverse range of perspectives were voiced and represented in these final data. Despite their different backgrounds, participants returned to the same four themes in all three workshops. Given that participants only attended one workshop and were unaware of the responses of participants in previous workshops, this indicates the reliability of these results. ‘Patient-centred care’ and ‘safety first’ were both considered fundamental principles, which aligned with the results of the context assessment study.( reference to Manuscript 1, submitted to Scientific Reports) There is a need for clear definitions of “virtual hospitals” and “virtual healthcare.” This research addressed an important gap in pre-implementation literature on virtual hospitals. 4,20 Although this study is specific to the Australian private hospital context, it offers healthcare decision-makers information to guide to both hospital co-design processes and the principles that underpin a high-quality virtual hospital. The strong emphasis on patient-centred care that authentically involves family members and carers aligns with democracy Co’s grey literature report on their co-design of an Australian public-private partnership hospital-in-the-home. 17 Likewise, the need for simple and reliable technology, and the stakeholder enthusiasm about digital health opportunities aligned with democracy Co’s results. Further research is needed to identify whether these results are replicated in other countries and contexts. Limitations The scope of this study was to identify agreed components of an overarching vision and set of principles for the virtual hospital. Additional co-design processes will be required to develop new models of care, including a more diverse group of health consumers and carers. Further research will be required to determine whether adaptations to the principles are necessary. This study was conducted in an Australian private not-for-profit healthcare setting which may influence the generalisability of these results. Additional research in other settings is required. Conclusion Bringing together health consumers, informal carers, clinicians, healthcare executives, informal carers, researchers, and government stakeholders enabled robust discussion and strong agreement on the major data themes and agreed principles for a private virtual hospital. There was strong alignment of responses between the three workshops indicating good reliability of these results. Authentically patient-centred care – “take the care to the patient” – and safety first were the strongest messages across all stakeholder groups. References Edgar, K. et al. Admission avoidance hospital at home. Cochrane Database Syst Rev. 3 (2024). Norman, G., Bennett, P. & Vardy, E. R. L. C. Virtual wards: a rapid evidence synthesis and implications for the care of older people. Age Ageing 52, afac319 (2023). Moore, G., Du Toit, A., Jameson, B. & Harris, M. Rapid Evidence Scan: The Effectiveness of Virtual Hospital Models of Care. Sax Institute https://doi.org/10.57022/lwxq3617 (2020). Wallis, J. A. et al. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev. 3 (2024). Lai, Y. F. & Ko, S. Q. Time to shift the research agenda for Hospital at Home from effectiveness to implementation. Cochrane Database Syst Rev 3 (2024). Annis, T. et al. Rapid implementation of a COVID-19 remote patient monitoring program. JAMIA 27, 1326–1330 (2020). Shaw, M. et al. rpavirtual: Key lessons in healthcare organisational resilience in the time of COVID-19. Int J Health Plann Manage 37, 1229–1237 (2022). Shaw, J., Brewer, L. C. & Veinot, T. Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review. JMIR Formative Research 5, (2020). Brody, A. A. et al. Starting Up a Hospital at Home Program: Facilitators and Barriers to Implementation. J Am Geriatr Soc 67, 588–595 (2019). Dinesen, B. et al. Implementation of the concept of home hospitalisation for heart patients by means of telehomecare technology: integration of clinical tasks. Int J Integr Care 7, e17 (2007). Sims, J., Rink, E., Walker, R. & Pickard, L. The introduction of a hospital at home service: A staff perspective. J Interprof Care 11, 217–224 (1997). Singh, D. R., Sah, R. K., Simkhada, B. & Darwin, Z. Potentials and challenges of using co-design in health services research in low- and middle-income countries. Glob Health Res Policy 8, 5 (2023). Vargas, C., Whelan, J., Brimblecombe, J. & Allender, S. Co-creation, co-design, co-production for public health: a perspective on definition and distinctions. Public Health Res Pract 32, (2022). Butler, T. et al. A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians. Int J Environ Res Public Health 19, 16166 (2022). Grindell, C., Coates, E., Croot, L. & O’Cathain, A. The use of co-production, co-design and co-creation to mobilise knowledge in the management of health conditions: a systematic review. BMC Health Serv Res 22, 877 (2022). Ní Shé, É. & Harrison, R. Mitigating unintended consequences of co-design in health care. Health Expect 24, 1551–1556 (2021). democracyCo. My Home Hospital Start-up Co-Design. https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/my+home+hospital+start-up+co-design+report (2020). Greenhalgh, T. et al. Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics. Front Digit Health 3, (2021). Braun, V., Clarke, V., Hayfield, N. & Terry, G. Thematic Analysis. in Handbook of Research Methods in Health Social Sciences (ed. Liamputtong, P.) 843–860 (Springer, 2019). Lai, Y. F. & Ko, S. Q. Time to shift the research agenda for Hospital at Home from effectiveness to implementation. Cochrane Database Syst Rev. 3 (2024). Declarations Acknowledgements The research team would like to acknowledge the invaluable contribution of the consumers and carers who participated in this study. We would also like to acknowledge all participants, within and external to the health service, for their contributions to this work. Thank you to Christopher Henderson who assisted with participant recruitment. Thanks also go to the members of the Virtual Hospital Steering Committee who were involved in planning the service, and who liaised with the research team throughout the study. Author Contributions OF led all aspects of the research. OF, AB and SK conceptualised the research program. OF, AB, SK, IS, and S-ES contributed to the development of the research protocol and methods. OF, KM, AB, SK, IS, S-ES, EM, WC and CG participated in data collection and preliminary analysis following each workshop. BM transcribed audio recordings. OF and BM analysed the qualitative data, with input from CG. All authors contributed to development and confirmation of the themes. OF wrote the bulk of the manuscript, with input from all authors. All authors approved the final manuscript. OF, KM, CG, WC, EM and BM are academic authors. AB, SK, and S-ES are industry authors. IS is both an academic and industry author. Data Availability Statement 'The data for this study will not be shared as it is potentially identifiable, and we do not have permission from the participants or ethical approval to do so. Transcripts clearly identify roles and responsibilities of participants throughout, both explicitly and implicitly, and are not able to be de-identified. Any questions or requests relating to these data please contact the corresponding author, or the UnitingCare Human Research Ethics Committee at [email protected] . Additional Information Financial Disclosure Statement Funding for this research was received from the industry partner UnitingCare Queensland. This funding paid, in full or part, the salaries of OF, KM, EM, WC, BM and CG. Authors S-ES, IS, and AB are employees of the funder and contributed to the research in-kind. SK is an independent doctor who contributed to the research in kind. All authors except BM participated in data collection. All authors participated in analysis and interpretation of data. Authors were not precluded from accessing data in the study, and all authors accept responsibility to submit for publication. Competing Interests Authors A.B., S-E.S. and I.S. are employees of the funder, UnitingCare Queensland. A.B. and S-E.S. had a direct role in implementation of the virtual hospital. No financial or other benefit other than the authors’ usual salary was received from UnitingCare Queensland. All intellectual property relating to this research is owned by Wesley Research Institute. UnitingCare Queensland has no ownership of intellectual property and no access to data created during this study. The other authors have no competing interests to declare. STROBE Guideline This manuscript complies with the relevant EQUATOR reporting guideline: the Standards for Reporting Implementation Studies (StaRI) Statement. Tables Table 1, Workshop Participants n (%) Workshop participation Workshop One – face-to-face (focus groups x3) 10 (27.78%) Workshop Two – online (focus groups x3) 17 (47.22%) Workshop Three – online (focus groups x2) 9 (25.00%) Total 36 (100.00%) Role/s* Consumers 4 (8.00%) Carers (informal/family) 3 (6.00%) Health service leadership 4 (8.00%) Hospital leadership 6 (12.00%) Aged care/family/disability services leadership 2 (4.00%) Aged care staff 5 (10.00%) VMO/Doctor 5 (10.00%) Nurses 9 (18.00%) Allied health 3 (6.00%) Public health stakeholders 4 (12.00%) Researchers 5 (10.00%) Total 50 (100.00%) Location Metropolitan 33 (91.67%) Regional 2 (5.56%) Rural/Remote 1 (2.78%) *Some participants had more than one role Additional Declarations Competing interest reported. Authors A.B., S-E.S. and I.S. are employees of the funder, UnitingCare Queensland. A.B. and S-E.S. had a direct role in implementation of the virtual hospital. No financial or other benefit other than the authors’ usual salary was received from UnitingCare Queensland. All intellectual property relating to this research is owned by Wesley Research Institute. UnitingCare Queensland has no ownership of intellectual property and no access to data created during this study. The other authors have no competing interests to declare. Cite Share Download PDF Status: Published Journal Publication published 07 Mar, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 17 Mar, 2025 Reviews received at journal 15 Mar, 2025 Reviewers agreed at journal 05 Mar, 2025 Reviewers agreed at journal 26 Dec, 2024 Reviewers agreed at journal 17 Oct, 2024 Reviews received at journal 06 Aug, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers invited by journal 15 Jul, 2024 Editor assigned by journal 15 Jul, 2024 Editor invited by journal 12 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 04 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Fisher","email":"data:image/png;base64,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","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":true,"prefix":"","firstName":"Olivia","middleName":"J.","lastName":"Fisher","suffix":""},{"id":328393652,"identity":"7f7e67e3-c9c3-47c6-a89f-29b57dc594f0","order_by":1,"name":"Belinda Moshi","email":"","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Belinda","middleName":"","lastName":"Moshi","suffix":""},{"id":328393654,"identity":"4d0ffda4-303a-4254-9ff5-b707ffc0af62","order_by":2,"name":"Kelly McGrath","email":"","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Kelly","middleName":"","lastName":"McGrath","suffix":""},{"id":328393657,"identity":"586b8333-6e61-4dc6-9924-7b84f148a3e4","order_by":3,"name":"Andrew Barron","email":"","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Barron","suffix":""},{"id":328393659,"identity":"3044607f-684c-41b5-aa68-b5bda96c9f31","order_by":4,"name":"Shanthi Kanagarajah","email":"","orcid":"","institution":"Queensland Physician Care","correspondingAuthor":false,"prefix":"","firstName":"Shanthi","middleName":"","lastName":"Kanagarajah","suffix":""},{"id":328393661,"identity":"6234743b-8ad8-493d-97bf-5254e23cfd66","order_by":5,"name":"Ian Smith","email":"","orcid":"","institution":"St Andrew's War Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Smith","suffix":""},{"id":328393662,"identity":"aa918699-5cbe-4726-b180-9a8a97747a99","order_by":6,"name":"Sue-Ellen Smith","email":"","orcid":"","institution":"BlueCare Community","correspondingAuthor":false,"prefix":"","firstName":"Sue-Ellen","middleName":"","lastName":"Smith","suffix":""},{"id":328393663,"identity":"d039d64a-47f5-4ea5-8134-d078bc4ed16a","order_by":7,"name":"Elizabeth Martin","email":"","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Martin","suffix":""},{"id":328393665,"identity":"91d15594-b71d-4539-aab1-04178b312948","order_by":8,"name":"Wendell Cockshaw","email":"","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Wendell","middleName":"","lastName":"Cockshaw","suffix":""},{"id":328393667,"identity":"39ea8a6b-2e6f-41ec-9d80-6162bc6c0394","order_by":9,"name":"Caroline Grogan","email":"","orcid":"","institution":"Wesley Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"","lastName":"Grogan","suffix":""}],"badges":[],"createdAt":"2024-07-04 05:07:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4683810/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4683810/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-026-41742-6","type":"published","date":"2026-03-07T16:00:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60604745,"identity":"a543f15d-1f2c-43fa-90db-a1e43f386abd","added_by":"auto","created_at":"2024-07-18 16:39:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60651,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrinciples for the Virtual Hospital\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4683810/v1/a3a26075c48b29ce528bb40d.png"},{"id":104250870,"identity":"b07ebf40-b2d6-4b7c-a9e4-6da0d647a4b4","added_by":"auto","created_at":"2026-03-09 16:10:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":613772,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4683810/v1/dc187b60-5736-429a-8bf7-11adfe4baab5.pdf"}],"financialInterests":"Competing interest reported. Authors A.B., S-E.S. and I.S. are employees of the funder, UnitingCare Queensland. A.B. and S-E.S. had a direct role in implementation of the virtual hospital. No financial or other benefit other than the authors’ usual salary was received from UnitingCare Queensland. All intellectual property relating to this research is owned by Wesley Research Institute. UnitingCare Queensland has no ownership of intellectual property and no access to data created during this study. The other authors have no competing interests to declare.","formattedTitle":"Take the care to the patient: Co-designed principles for establishment of a virtual hospital","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years there has been a rapid global expansion of virtual hospitals, virtual wards, and hospital in the home services, henceforth referred to collectively as \u0026ldquo;virtual hospitals.\u0026rdquo; Research evidence is critical to inform healthcare decision makers considering implementing a virtual hospital. However, although there is strong evidence for the safety and clinical effectiveness of virtual hospitals,\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e implementation research has lagged.\u003csup\u003e4,5\u003c/sup\u003e There is substantial variance between models of care described as virtual hospitals,\u003csup\u003e3\u003c/sup\u003e and little guidance on selection or design of a suitable model of care for various healthcare settings and needs. There is acknowledgement in the literature that implementation of many virtual hospitals has been rushed in the context of the COVID-19 pandemic.\u003csup\u003e6\u0026ndash;8\u003c/sup\u003e One study described setting up a COVID-19 virtual ward as being like building a plane while flying it.\u003csup\u003e6\u003c/sup\u003e Consequently, the majority of existing implementation literature has been retrospective and reliant on participant reflections.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOf the few published pre-implementation studies, \u003csup\u003e9\u0026ndash;11\u003c/sup\u003e only one reported a collaborative design process,\u003csup\u003e10\u003c/sup\u003e and none used authentic consumer-inclusive co-design methods. Co-design in healthcare brings together health consumers and other stakeholders such as clinicians, healthcare executives/decision makers, informal/family carers, community and government representatives to develop solutions to complex healthcare problems.\u003csup\u003e12\u0026ndash;14\u003c/sup\u003e Typically the goal or problem is pre-defined, and stakeholders come together through a range of methods to provide input and ideally agree on solutions. These collaborative processes aim to design healthcare services that are fit-for-purpose for consumers and healthcare providers alike, enable knowledge mobilisation, and reduce research waste.\u003csup\u003e13,15,16\u003c/sup\u003e. Although Dinesen et al. \u003csup\u003e10\u003c/sup\u003e described using a pre-implementation \u0026lsquo;design panel\u0026rsquo; of clinicians to guide workflows and clinical processes of a hospital-in-the-home, no consumer or carer involvement was reported.\u003c/p\u003e \u003cp\u003eOne previous grey literature virtual hospital co-design study was identified.\u003csup\u003e17\u003c/sup\u003e My Home Hospital in South Australia used a co-design process to develop a clinical pathway and patient journal prior to commencement of a public hospital-in-the-home service. No research that addressed the development of a long-term vision or overarching principles of a virtual hospital was identified. Having a long-term strategic vision and clear set of principles are integral components of virtual hospital design according to healthcare stakeholders.\u003csup\u003e17\u003c/sup\u003e(reference to Manuscript 1, submitted to Scientific Reports)\u003c/p\u003e \u003cp\u003eThis research aimed to inform the design of a new private Australian virtual hospital by: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) understanding the virtual healthcare needs, preferences and perspectives of a broad range of stakeholders; and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) agreeing upon themes to inform a shared vision and set of principles.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA qualitative pre-implementation co-design study in July-Sep 2023 which involved three workshops with key stakeholders, one face-to-face in Brisbane, Queensland and two online. This study was the second phase of a research program to inform the design and implementation of a private Australian virtual hospital. The first phase was a context assessment to determine contextual barriers and enablers to implementation. The context assessment results and additional information about the setting and theoretical approach used are reported elsewhere (reference to Manuscript 1, submitted to Scientific Reports). This manuscript reports results of the co-design workshops only. This research was informed by the Planning and Evaluating Remote Consultation Services (PERCS) implementation science framework.\u003csup\u003e18\u003c/sup\u003e PERCS was developed during the COVID-19 pandemic to inform the rapid roll-out of virtual consultations in the United Kingdom\u0026rsquo;s National Health Service. It provides an evidence- and theory-based conceptual framework and guidance on stakeholders that need to be considered in the planning for remote consultation services.\u003c/p\u003e \u003cp\u003eObjectives\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify and agree upon components (themes) of a ten-year vision to inform ongoing design and development of the virtual hospital.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify and agree upon recommended principles for the virtual hospital.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCo-design process\u003c/h2\u003e \u003cp\u003eThree workshops were conducted. Each workshop was audio recorded. The face-to-face workshop was two hours, and the two online workshops were 90 minutes. Participants were informed that they were welcome to provide additional written feedback by email in the two weeks following the workshop. Each workshop consisted of a series of activities in the full group, and in small focus groups. Each focus groups was facilitated by a member of the research team to ensure that conversations remained focused on the research question and all participants had the opportunity to share their perspectives. Participants attended one workshop only and were not informed of the results of previous workshops. To minimise the potential impact of any imbalance of power between participants, e.g., a health consumer and a doctor in the same focus group, the activities involved both group discussions and opportunities to provide individual and anonymous feedback. Workshop activities:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eCritique and confirmation of the context assessment results\u003c/em\u003e. Each workshop commenced with a presentation of context assessment results, followed by a whole-of-workshop group activity to critique and/or confirm the results. A summary of the responses was written on the whiteboard by the workshop facilitator and participants had the opportunity to provide clarification or correction of the summarised findings.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eCritique of the vision and principles\u003c/em\u003e. A draft ten-year vision and set of principles derived from the context assessment results were presented and participants split into focus groups of between three to six people, each with a facilitator from the research team, to critique the drafts. Each focus group then provided feedback to the whole-of-workshop group, which was summarised on a white board by the workshop facilitator. The summary was checked and clarified with participants during the discussion.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eDevelopment of next steps\u003c/em\u003e. Participants were asked to consider the tasks/steps required to reach the vision within ten years. Steps were developed individually and shared anonymously by either 1) using post-it notes placed along a timeline in the face-to-face workshop; or 2) on a shared OneDrive file with a ten-year timeline which all participants were able to edit anonymously during the online workshops.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003ePurposeful selection was used to identify participants. All participants of a phase one interview (n\u0026thinsp;=\u0026thinsp;37) were invited to a workshop unless they had previously expressed that they were not interested in attending a workshop (n\u0026thinsp;=\u0026thinsp;1). Additional stakeholders who had not been interviewed were identified by the research team using a snowball sampling strategy. The focus of participant selection was on representation of key stakeholder groups and roles, as outlined in results Table One. Therefore, sample size and selection was focused on representation rather than data saturation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eQualitative analysis\u003c/h2\u003e \u003cp\u003eFollowing each workshop the research team conducted a one-hour debrief session to discuss initial impressions, emerging themes, reflections on engagement and participation, and any necessary process-related adaptations for future workshops. These debrief sessions were recorded and transcribed and formed part of the analysis process.\u003c/p\u003e \u003cp\u003eBecause of the value of inductive coding, we chose to use a pragmatic thematic coding methodology where we coded point (topic) by point, not line by line.\u003csup\u003e19\u003c/sup\u003e. In this way, we were able to develop descriptive codes and themes that accurately represented the data, within the health service\u0026rsquo;s required timeframe. OF and BM coded all workshop transcripts, and regular discussions were held with CG to agree on and confirm the descriptive codes and themes. These were then compared with the debrief session transcripts to ensure alignment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Storage\u003c/h2\u003e \u003cp\u003eAll electronic data were stored on secure password-protected servers managed by the research institute, and paper-based data were stored in a locked file storage in a secure swipe-card access facility. Data management and retention complies with the National Health and Medical Research Council\u0026rsquo;s Management of Data and Information in Research guide.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations and Approval\u003c/h2\u003e \u003cp\u003eParticipation was by informed consent. To avoid any potential perception of coercion to participate, consent was obtained by a member of the research team who did not have any supervisory relationship with the participant. To address any potential influence that imbalance of power between group members might have on participant responses during the workshop the activities included opportunities to provide feedback in small, facilitated focus groups, in the whole group, and individually. There was also an option to provide written feedback directly to the research team following the workshop. Ethical approval was received on 9 January 2023 from the UnitingCare Queensland Human Research Ethics Committee, Reference: Fisher_20221207. This research was conducted in accordance with the relevant guidelines and regulations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eEight focus groups were facilitated across the three workshops. The majority of participants (n=26, 72.22%) attended an online workshop, with three (8.33%) attending from outside of a metropolitan area (Table 1). One participant provided additional written background information in the week following the workshop by email.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[INSERT TABLE 1 HERE]\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eThemes\u003c/em\u003e\u003cem\u003e\u0026nbsp;and Subthemes\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eNo participant identifiers have been included for workshop quotes because it was not possible to accurately identify each participant from the audio recordings due to the large size of some groups. Participants confirmed the considerations, enablers and barriers identified in the context assessment. There was strong alignment in responses across the three workshops, with the exception of a greater focus on rural and remote issues in the online workshops. Participants were enthusiastic about the potential of the virtual hospital and stated that they appreciated the opportunity to provide input from their perspectives. Across the three workshops, the following overarching themes and sub-themes emerged:\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eTheme One: Take the care to the patient\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eWorkshop participants reported that the major advantage of a virtual hospital, as opposed to care provided in a physical hospital, is that patients can receive hospital care in their own homes, avoiding unnecessary travel and time away from their communities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSub-themes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea. Create and address demand for timely healthcare \u0026lsquo;in place\u0026rsquo;:\u003c/em\u003e Customers and patients are beginning to expect convenient and timely virtual health services, which are accessible in their own homes or communities \u0026ndash; i.e., \u0026lsquo;in place\u0026rsquo;. However, it was acknowledged by participants that work is needed to effectively build familiarity with and greater demand for these \u0026lsquo;in place\u0026rsquo; services in the general population. Younger people were seen as central to developing this demand within the community.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;One of the questions that I would love answered is, \u0026lsquo;if you could have your care episode\u0026hellip; at home\u0026hellip; do you think you would take advantage of that?\u0026rsquo; Because I found that most people haven\u0026apos;t even thought about it\u0026hellip; It doesn\u0026apos;t occur to the clinicians, and it doesn\u0026apos;t occur to the to the patients or carers either. And it doesn\u0026apos;t need to be in their own home, it could be in their daughter\u0026apos;s home or their son\u0026apos;s home or their parent\u0026apos;s home. And it\u0026apos;s just sort of and thinking about and, and if that had to happen, what would need to be in place for that?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb. Removing geographical boundaries:\u003c/em\u003e There was strong support for provision of virtual hospital services to rural and remote areas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ec. Inclusive and appropriate\u003c/em\u003e: Provide patients with services that are culturally appropriate, accessible and inclusive for people from diverse backgrounds.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ed. Support the transition between services\u003c/em\u003e: Real-time communication between services is critical to smooth patient transitions. Patients frequently transition between public and private healthcare providers, ambulance, general practice, and aged care providers. Currently, there is a lack of streamlined communication between services to enable smooth transitions, which can be challenging for both patients and carers, and providers. Improving transitions through care navigation or more effective communication strategies is important.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;And I would like to think that we would be partnering with public hospitals or statewide systems working that, that we know patients do flit from public to private and that they would need a system in place where the virtual records would be accessible by all.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eTheme Two: Virtual is the mechanism, the care is real\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eParticipants felt strongly that virtual healthcare must be of equivalent safety and quality to face-to-face healthcare. The ability to develop trusting relationships between providers and patients was seen as critical, and there was variance in responses about whether this is possible via telehealth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubthemes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea. Less than a physical hospital:\u0026nbsp;\u003c/em\u003eThere was a perception from some participants that the term \u0026ldquo;virtual\u0026rdquo; indicated that the care was not \u0026ldquo;real,\u0026rdquo; raising the question of whether the language of \u0026ldquo;virtual hospital\u0026rdquo; may need to be amended. There was a lack of agreement on this point, which indicates the need for a clear definition of virtual healthcare. Concerns about the need for physical examination were raised by multiple participants. \u0026nbsp;The importance of supportive physical touch as part of a healthcare consultation was raised, and some participants believed that this was a major limitation of telehealth.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Personally, I have a very different feeling with the word virtual. The feeling I get is \u0026lsquo;not real\u0026rsquo;.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb. More than a physical hospital:\u0026nbsp;\u003c/em\u003eRapidly advancing technology is opening opportunities for monitoring that is likely to be more accurate and potentially faster at detecting changes in patients\u0026rsquo; clinical presentation than previously possible. \u0026ldquo;Hospitals harm people\u0026rdquo; was a consistent message in both the context assessment and co-design studies. Hospital acquired infection was a major concern raised about traditional hospitals, as well as difficulties for some patients in adapting to a ward environment, e.g., patients with dementia, which can result in confusion, falls, and other adverse outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We know for many reasons it\u0026apos;s safer from the infection perspective and a number of other things, they are with family, they [family] can provide care, but they [patients] really need\u0026hellip; the input of their doctor.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants felt that younger people adapt more easily to new technologies and are less likely to see virtual healthcare as inferior to face-to-face. Younger people were described as easily forming relationships with people online, without the need for face-to-face contact.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eTheme Three: Be ambitious, but build a strong foundation.\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThere were many comments relating to building a strong foundation for the hospital, particularly relating to safety, procedures, clinical governance, and appropriate technology. These foundational elements were seen as required precursors to any new services. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubthemes:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea. Safety first\u003c/em\u003e: This was one of the strongest messages from the co-design workshops. Safe care was seen as separate to high-quality care, and both were considered necessary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb. Technology that\u0026rsquo;s fit for purpose\u003c/em\u003e: Participants raised the need for technology that is\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEasily adaptable to incorporate new services and technologies as they are developed.\u003c/li\u003e\n \u003cli\u003eReliable.\u003c/li\u003e\n \u003cli\u003eAffordable for both the health service and the patient.\u003c/li\u003e\n \u003cli\u003eAble to integrate with other existing systems.\u003c/li\u003e\n \u003cli\u003eEasy to use, both for providers and consumers/carers.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTrained with First Nations and diverse voices.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026ldquo;Everybody in our [focus] group has had the experience of having programs that don\u0026apos;t talk to each other, unstable platform that we\u0026apos;re managing programs on that we-, you know, program falling over, IT not being in a stable environment, programs going down, no accessibility.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ec. More than just acute care\u003c/em\u003e: Participants were enthusiastic about the possibility of providing comprehensive care to patients, including acute, sub-acute, proactive and rehabilitation services via the virtual hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ed. Must be cost-effective\u003c/em\u003e: Both for the healthcare provider and for patients. Participants described advantages to patients such as reduced travel time and expenses, as well as additional costs to informal carers such as time off work or away from usual tasks to support a virtual hospital patient.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eTheme Four: Build the right workforce\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe \u0026ldquo;right\u0026rdquo; workforce was described as one that is comfortable with technology, able to take on the responsibility of autonomous patient care, and ideally co-located to encourage interdisciplinary collaboration, effective communication, and planning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubthemes:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea. Workforce opportunities\u003c/em\u003e: For health professionals who have barriers to being able to provide face-to-face care e.g., due to injury, a virtual hospital may be an opportunity to enter, extend or patch their healthcare career. The flexibility that virtual healthcare offers providers was seen as an important advantage to attract a high-quality workforce.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb. Informal carers are a critical workforce\u003c/em\u003e: Participants felt that without the important contribution of informal carers supporting patients at home during the admission the virtual hospital would not be viable. Participants therefore felt that the increased burden of care and responsibility on carers was important to consider, including the potential emotional toll of taking on a role that may require monitoring and escalation if a patient\u0026rsquo;s health declines. \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;You\u0026apos;re taking the work that would normally done by the health care system and requiring the carers to do it. And we need to be immensely aware of the personal cost\u0026hellip; Often that\u0026apos;s not accounted for in business statements and financial assessments\u0026hellip; it takes you out of workforce and other activities in your life, whether they\u0026apos;re volunteering, caring for children or other activities.\u0026rdquo;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003ePrinciples\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eBoth \u0026ldquo;patient centred\u0026rdquo; and \u0026ldquo;safety first\u0026rdquo; were raised by the majority of focus groups as the key principles for the Virtual Hospital and this was confirmed in whole of workshop group discussions. The opportunity to provide truly patient-centred care in their own home environment or community was considered a distinct advantage of virtual healthcare. Through collaborative discussions, the groups identified that \u0026ldquo;safety first\u0026rdquo; needed to underpin all principles, rather than being a standalone principle, leaving \u0026ldquo;patient centred\u0026rdquo; as the highest priority principle (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[INSERT FIGURE 1 HERE]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere was strong alignment of themes across the three workshops: 1) take the care to the patient; 2) virtual is the mechanism, the care is real; 3) be ambitious but build a strong foundation; and 4) build the right workforce. Using a co-design approach created enthusiasm and buy-in from the invited stakeholders, who were able to express and discuss their ideas, concerns, and considerations. The robust discussions between varied stakeholders in the workshops meant that a diverse range of perspectives were voiced and represented in these final data. Despite their different backgrounds, participants returned to the same four themes in all three workshops. Given that participants only attended one workshop and were unaware of the responses of participants in previous workshops, this indicates the reliability of these results. \u0026lsquo;Patient-centred care\u0026rsquo; and \u0026lsquo;safety first\u0026rsquo; were both considered fundamental principles, which aligned with the results of the context assessment study.( reference to Manuscript 1, submitted to Scientific Reports) There is a need for clear definitions of \u0026ldquo;virtual hospitals\u0026rdquo; and \u0026ldquo;virtual healthcare.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThis research addressed an important gap in pre-implementation literature on virtual hospitals.\u003csup\u003e4,20\u003c/sup\u003e Although this study is specific to the Australian private hospital context, it offers healthcare decision-makers information to guide to both hospital co-design processes and the principles that underpin a high-quality virtual hospital. The strong emphasis on patient-centred care that authentically involves family members and carers aligns with democracy Co\u0026rsquo;s grey literature report on their co-design of an Australian public-private partnership hospital-in-the-home.\u003csup\u003e17\u003c/sup\u003e Likewise, the need for simple and reliable technology, and the stakeholder enthusiasm about digital health opportunities aligned with democracy Co\u0026rsquo;s results. Further research is needed to identify whether these results are replicated in other countries and contexts.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e The scope of this study was to identify agreed components of an overarching vision and set of principles for the virtual hospital. Additional co-design processes will be required to develop new models of care, including a more diverse group of health consumers and carers. Further research will be required to determine whether adaptations to the principles are necessary. This study was conducted in an Australian private not-for-profit healthcare setting which may influence the generalisability of these results. Additional research in other settings is required.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBringing together health consumers, informal carers, clinicians, healthcare executives, informal carers, researchers, and government stakeholders enabled robust discussion and strong agreement on the major data themes and agreed principles for a private virtual hospital. There was strong alignment of responses between the three workshops indicating good reliability of these results. Authentically patient-centred care \u0026ndash; \u0026ldquo;take the care to the patient\u0026rdquo; \u0026ndash; and safety first were the strongest messages across all stakeholder groups.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEdgar, K. \u003cem\u003eet al.\u003c/em\u003e Admission avoidance hospital at home. Cochrane Database Syst Rev. 3 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman, G., Bennett, P. \u0026amp; Vardy, E. R. L. C. Virtual wards: a rapid evidence synthesis and implications for the care of older people. Age Ageing 52, afac319 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore, G., Du Toit, A., Jameson, B. \u0026amp; Harris, M. Rapid Evidence Scan: The Effectiveness of Virtual Hospital Models of Care. Sax Institute \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.57022/lwxq3617\u003c/span\u003e\u003cspan address=\"10.57022/lwxq3617\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallis, J. A. \u003cem\u003eet al.\u003c/em\u003e Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev. 3 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai, Y. F. \u0026amp; Ko, S. Q. Time to shift the research agenda for Hospital at Home from effectiveness to implementation. Cochrane Database Syst Rev 3 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnnis, T. \u003cem\u003eet al.\u003c/em\u003e Rapid implementation of a COVID-19 remote patient monitoring program. JAMIA 27, 1326\u0026ndash;1330 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw, M. \u003cem\u003eet al.\u003c/em\u003e rpavirtual: Key lessons in healthcare organisational resilience in the time of COVID-19. Int J Health Plann Manage 37, 1229\u0026ndash;1237 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw, J., Brewer, L. C. \u0026amp; Veinot, T. Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review. JMIR Formative Research 5, (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrody, A. A. \u003cem\u003eet al.\u003c/em\u003e Starting Up a Hospital at Home Program: Facilitators and Barriers to Implementation. J Am Geriatr Soc 67, 588\u0026ndash;595 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDinesen, B. \u003cem\u003eet al.\u003c/em\u003e Implementation of the concept of home hospitalisation for heart patients by means of telehomecare technology: integration of clinical tasks. Int J Integr Care 7, e17 (2007).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSims, J., Rink, E., Walker, R. \u0026amp; Pickard, L. The introduction of a hospital at home service: A staff perspective. J Interprof Care 11, 217\u0026ndash;224 (1997).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh, D. R., Sah, R. K., Simkhada, B. \u0026amp; Darwin, Z. Potentials and challenges of using co-design in health services research in low- and middle-income countries. Glob Health Res Policy 8, 5 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVargas, C., Whelan, J., Brimblecombe, J. \u0026amp; Allender, S. Co-creation, co-design, co-production for public health: a perspective on definition and distinctions. Public Health Res Pract 32, (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButler, T. \u003cem\u003eet al.\u003c/em\u003e A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians. Int J Environ Res Public Health 19, 16166 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrindell, C., Coates, E., Croot, L. \u0026amp; O\u0026rsquo;Cathain, A. The use of co-production, co-design and co-creation to mobilise knowledge in the management of health conditions: a systematic review. BMC Health Serv Res 22, 877 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eN\u0026iacute; Sh\u0026eacute;, \u0026Eacute;. \u0026amp; Harrison, R. Mitigating unintended consequences of co-design in health care. Health Expect 24, 1551\u0026ndash;1556 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003edemocracyCo. My Home Hospital Start-up Co-Design. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/my+home+hospital+start-up+co-design+report\u003c/span\u003e\u003cspan address=\"https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/my+home+hospital+start-up+co-design+report\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenhalgh, T. \u003cem\u003eet al.\u003c/em\u003e Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics. Front Digit Health 3, (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun, V., Clarke, V., Hayfield, N. \u0026amp; Terry, G. Thematic Analysis. in \u003cem\u003eHandbook of Research Methods in Health Social Sciences\u003c/em\u003e (ed. Liamputtong, P.) 843\u0026ndash;860 (Springer, 2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai, Y. F. \u0026amp; Ko, S. Q. Time to shift the research agenda for Hospital at Home from effectiveness to implementation. Cochrane Database Syst Rev. 3 (2024).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research team would like to acknowledge the invaluable contribution of the consumers and carers who participated in this study. We would also like to acknowledge all participants, within and external to the health service, for their contributions to this work. Thank you to Christopher Henderson who assisted with participant recruitment. Thanks also go to the members of the Virtual Hospital Steering Committee who were involved in planning the service, and who liaised with the research team throughout the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOF led all aspects of the research. OF, AB and SK conceptualised the research program. OF, AB, SK, IS, and S-ES contributed to the development of the research protocol and methods. OF, KM, AB, SK, IS, S-ES, EM, WC and CG participated in data collection and preliminary analysis following each workshop. BM transcribed audio recordings. OF and BM analysed the qualitative data, with input from CG. All authors contributed to development and confirmation of the themes. OF wrote the bulk of the manuscript, with input from all authors. All authors approved the final manuscript. OF, KM, CG, WC, EM and BM are academic authors. AB, SK, and S-ES are industry authors. IS is both an academic and industry author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability Statement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026apos;The data for this study will not be shared as it is potentially identifiable, and we do not have permission from the participants or ethical approval to do so. Transcripts clearly identify roles and responsibilities of participants throughout, both explicitly and implicitly, and are not able to be de-identified. Any questions or requests relating to these data please contact the corresponding author, or the UnitingCare Human Research Ethics Committee at [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdditional Information\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinancial Disclosure Statement\u003c/p\u003e\n\u003cp\u003eFunding for this research was received from the industry partner UnitingCare Queensland. This funding paid, in full or part, the salaries of OF, KM, EM, WC, BM and CG. Authors S-ES, IS, and AB are employees of the funder and contributed to the research in-kind. SK is an independent doctor who contributed to the research in kind. All authors except BM participated in data collection. All authors participated in analysis and interpretation of data. Authors were not precluded from accessing data in the study, and all authors accept responsibility to submit for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eAuthors A.B., S-E.S. and I.S. are employees of the funder, UnitingCare Queensland. A.B. and S-E.S. had a direct role in implementation of the virtual hospital. No financial or other benefit other than the authors\u0026rsquo; usual salary was received from UnitingCare Queensland. All intellectual property relating to this research is owned by Wesley Research Institute. UnitingCare Queensland has no ownership of intellectual property and no access to data created during this study. The other authors have no competing interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSTROBE Guideline\u003c/p\u003e\n\u003cp\u003eThis manuscript complies with the relevant EQUATOR reporting guideline: the Standards for Reporting Implementation Studies (StaRI) Statement.\u0026nbsp;\u003c/p\u003e"},{"header":"Tables","content":"\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTable 1, Workshop Participants\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003en (%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eWorkshop participation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eWorkshop One \u0026ndash; face-to-face\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e(focus groups x3)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e10 (27.78%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eWorkshop Two \u0026ndash; online\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e(focus groups x3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e17 (47.22%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eWorkshop Three \u0026ndash; online\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e(focus groups x2)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e9 (25.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTotal\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e36 (100.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eRole/s*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eConsumers\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e4 (8.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eCarers (informal/family)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e3 (6.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eHealth service leadership\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e4 (8.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eHospital leadership\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e6 (12.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eAged care/family/disability services leadership\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e2 (4.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eAged care staff\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e5 (10.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eVMO/Doctor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e5 (10.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eNurses\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e9 (18.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eAllied health\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e3 (6.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003ePublic health stakeholders\u003c/span\u003e\u003c/p\u003e\n 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style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eResearchers\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.85pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e5 (10.00%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155.8pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp 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Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4683810/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4683810/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe aimed to inform design and implementation of a new Australian private virtual hospital by establishing co-designed principles and themes to inform a ten-year vision. This qualitative pre-implementation co-design study used an implementation science approach informed by the PERCS framework. Three workshops were held, one face-to-face in Brisbane, Australia, and two online. In each workshop, results of a prior barriers/enablers/considerations study were presented and critiqued by participants, followed by activities in focus groups. Thirty-six stakeholders from metropolitan, regional and rural areas participated including consumers, carers, health and aged care leadership, nurses, allied health providers, general practitioners, researchers, and public health stakeholders. There was strong enthusiasm, with some reservations such as clinical safety concerns. Four strong themes emerged: 1) Take the care to the patient; 2) Virtual is the mechanism, the care is real; 3) Be ambitious, but build a strong foundation; 4) Build the right workforce. These themes were repeated across all workshops, indicating good reliability of results. The strongest overall messages were the need for authentically patient-centred care and safety. Participants agreed that \u0026ldquo;safety first\u0026rdquo; underpinned all principles. Using an implementation science-informed, pre-implementation co-design approach led to stakeholder enthusiasm and findings which will inform implementation of the virtual hospital.\u003c/p\u003e","manuscriptTitle":"Take the care to the patient: Co-designed principles for establishment of a virtual hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:38:58","doi":"10.21203/rs.3.rs-4683810/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-17T11:28:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-15T21:28:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231782934490980934529214365770151711279","date":"2025-03-05T18:32:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131490498342539209315266214411003318443","date":"2024-12-27T00:11:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97034345542482551575408079184879855425","date":"2024-10-17T22:28:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-06T07:27:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217673524909526780626625701670828253327","date":"2024-07-25T10:59:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-15T15:29:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-15T15:27:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-12T12:27:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T05:02:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-04T05:06:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b785da63-a23f-4411-93cb-d52131b864fd","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34757565,"name":"Health sciences/Health care/Health services"},{"id":34757566,"name":"Health sciences/Health care/Occupational health"}],"tags":[],"updatedAt":"2026-03-09T16:06:10+00:00","versionOfRecord":{"articleIdentity":"rs-4683810","link":"https://doi.org/10.1038/s41598-026-41742-6","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-03-07 16:00:11","publishedOnDateReadable":"March 7th, 2026"},"versionCreatedAt":"2024-07-18 16:38:58","video":"","vorDoi":"10.1038/s41598-026-41742-6","vorDoiUrl":"https://doi.org/10.1038/s41598-026-41742-6","workflowStages":[]},"version":"v1","identity":"rs-4683810","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4683810","identity":"rs-4683810","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}